key: cord-1023300-hlobv8p6 authors: Hinrichs, Carl; Wiese‐Posselt, Miriam; Graf, Barbara; Geffers, Christine; Weikert, Beate; Enghard, Philipp; Aldejohann, Alexander; Schrauder, Annette; Knaust, Andreas; Eckardt, Kai‐Uwe; Gastmeier, Petra; Kurzai, Oliver title: Successful control of Candida auristransmission in a German COVID‐19 intensive care unit date: 2022-04-24 journal: Mycoses DOI: 10.1111/myc.13443 sha: 32ba46e135e9c025e66461d0b6c618f80d98b3b7 doc_id: 1023300 cord_uid: hlobv8p6 BACKGROUND: Candida aurisis a frequently multidrug‐resistant yeast species that poses a global health threat due to its high potential for hospital outbreaks. While C. auris has become endemic in parts of Asia and Africa, transmissions have so far rarely been reported in Western Europe except for Great Britain and Spain. We describe the first documented patient‐to‐patient transmission of C. auris in Germany in a COVID‐19 intensive care unit (ICU) and infection control measures implemented to prevent further spread of the pathogen. METHODS: Identification of C. auris was performed by MALDI‐TOF and confirmed by internal transcribed spacer (ITS) sequencing. Antifungal susceptibility testing was carried out. We conducted repeated cross‐sectional examinations for the presence of C. auris in the patients of the affected ICU and investigated possible routes of transmission. RESULTS: The index patient had been transferred to Germany from a hospital in Northern Africa and was found to be colonised with C. auris. The contact patient developed C. auris sepsis. Infection prevention and control (IPC) measures included strict isolation of the two C. auris patients and regular screening of non‐affected patients. No further case occurred during the subsequent weeks. Reusable blades used in video laryngoscope‐guided intubation were considered as the most likely vehicle of transmission. CONCLUSIONS: In view of its high risk of transmission, vigilance regarding C. auris colonisation in patients referred from endemic countries is crucial. Strict and immediate IPC measures may have the potential to prevent C. auris outbreaks. Candida aurisis an emerging yeast pathogen that is increasingly associated with hospital outbreaks worldwide. [1] [2] [3] Genomic epidemiology has suggested the simultaneous global emergence of several distinct clades. 4 Treatment of C. auris infections is hampered by the frequently reduced susceptibility to different classes of antifungal agents, including multi-and pan-antifungal resistance. 5 In some regions, especially in Africa and Asia, C. auris has become an endemic pathogen. 6 In Europe, large outbreaks have been reported recently from intensive care units (ICUs) in the United Kingdom and Spain. 7, 8 These outbreaks are often prolonged and difficult to contain. In Germany, only isolated cases of C. auris have been reported thus far. 9 Most of these cases have occurred in patients who had recently been in contact with hospitals / healthcare providers abroad. Although since the first published report the number of cases documented by the National Reference Center for Invasive Fungal Infections (NRZMyk) has increased to >25 (unpublished data), local transmission of the fungus has not yet been reported so far. 9 Since the onset of the COVID-19 pandemic, an increased number of C. auris infections in COVID-19 patients have been reported such as from India and United States. 10 Here, we describe the first documented transmission of C. auris in Germany between two critically ill COVID-19 patients, actions taken for infection prevention and control (IPC) and the identification of the probable path of transmission. In response to the high demand during the SARS-CoV-2 pandemic, our university hospital with over 3000 patient beds established several temporary COVID-19 ICUs. For this purpose, a building with a capacity of up to one hundred ICU beds on three levels was established. Each level is U-shaped with two wings (wing A and B) hosting between 15 and 24 beds each, with one to four beds in each room. Staff were recruited from other ICUs, operating rooms and non-intensive care units. The treatment spectrum included the full range of highlevel critical care, except ECMO (extracorporal membrane oxygenation) therapy, which was conducted only on other dedicated ICUs. As all patient data were anonymised for this report and microbiological diagnostics was clinical routine, ethics approval was not required according to §25 Berliner Landeskrankenhausgesetz (Berlin hospital law). Specimens for routine fungal analysis were inoculated on Sabouraud Glucose Selective Agar with gentamicin and chloramphenicol (Thermo Scientific/ Oxoid PO5086A) and BBL TM CHROMagar TM Candida Medium (BD). Agar plates were incubated at 28°C and 37°C, respectively, for up to seven days. Samples, such as cerebrospinal fluids (CSF), biopsies, tissue samples or bronchoalveolar lavage fluids (BAL), were also inoculated on brain-heart-infusion slants (BHI) with or without (CSF samples) gentamicin and chloramphenicol (Sifin Diagnostics GmbH) and incubated at 28°C for four weeks. For specimens from sterile compartments like CSF, a supplemental Sabouraud liquid medium (bioMérieux) was used and incubated at 28°C for seven days. Specimens for patient screening and environmental swabs were inoculated on CHROMagar™ Candida Plus (CHROMagar) and incubated at 37°C for four days. Yeast isolates were identified with VITEK ® MS v3.2.0 (bioMérieux), a system that uses Matrix-Assisted Laser Desorption Ionization Time-of-Flight (MALDI-TOF) technology. Susceptibility testing was done using VITEK ® 2 System with AST Y08 cards and ETEST gradient technology (bioMérieux). The first C. auris isolate of each patient was sequenced using the MiSeq TM system (Illumina, Inc) with an Illumina Internal Transcribed Spacer (ITS) rRNA sequencing protocol and amplicon primers ITS1-30F and ITS1-217R as described elsewhere. 11 In the NRZMyk, species, identification (ID) was confirmed using ITS1/2 sequencing as described earlier. 12 Oligonucleotide primers are shown in 5'-3' direction. Broth microdilution (BM) was performed using EUCAST reference methodology. 13 FKS hotspot regions were performed as described earlier. 12 All procedures that had required patient transport and all measures involving the use of medical devices on both C. auris patients were extracted from the electronic patient file together with dates and times. All such records sorted by device were tabulated, and On Day 90, the index patient was discharged and transferred to a rehabilitation clinic, while still being colonised with C. auris (inguinal crease, throat, nose and urine). On Day 73, following the patient's gradual and persistent improvement, he was transferred to a rehabilitation clinic while still colonised with C. auris (TBS, skin, wound, throat and nose). Initial and follow-up isolates of the index patient (NRZ2021-103, The index patient visited her general practitioner on Day 57 after discharge. One swab series was negative for C. auris (throat swab positive for C albicans). On Day 105 after discharge, the index patient was again re-admitted to our hospital due to an adrenal insufficiency; swab series and urine sample were without evidence of C. auris. The contact patient was re-admitted to an external hospital because of his chronic lung disease 45 days after discharge. One swab series still revealed evidence of C. auris colonisation (throat swab). Additional control screenings were conducted at the Infectious Diseases Outpatient Clinic of our hospital (Days 118, 139 and 160 after discharge). These three swab series and one sputum sample were negative for C. auris. On Day 202 after discharge, the contact patient was again re-admitted to our hospital for operative closure of the tracheostoma. At this time, while the swab series were negative, C. auris was detected in a sputum sample, indicating long-term colonisation. We report the patient-to-patient transmission of C. auris in a We would like to thank all healthcare personnel of Charité The data that support the findings of this study are available from the corresponding author upon reasonable request. 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